WIC Program
Manual Certification – Women (Required Fields)
Date: / WIC ID: / Preg BF Non-BF / New Certification Re-Certification
Demographics Information
Last Name: / First Name :
Hispanic or Latino: Yes No
Race: White Black/African American Asian Native Hawaiian/Pacific American Indian/Alaskan
If American Indian/Alaskan Native please select one of the following:
Boise Forte Fond du Lac Grand Portage Leech Lake Lower Sioux Upper Sioux White Earth
Mille Lacs Red Lake Mdewankanton Other Participant Declined
Additional Info tabs 1 and 2
Household Smoking: Yes No / Education Level:
Medical Home (Name of Medical Clinic):
Health Information-Pregnant
Current Pregnancy Information
Expecting Multiple Births / Diabetes Mellitus / Expected Delivery Date:______
Planned C-section / Gestational Diabetes / LMP Start Date:______/ Pre-Preg Weight:______
Hypertension or Pre-hypertension
Has Not Received Prenatal Care Yet / Date Prenatal Care Began:______
Requires Food Package III: Yes No / Date verified:______
Previous Pregnancy Information
Number of Pregnancies:______/ Number of Live Births:______/ Number of WIC Pregnancies:______
Number of Pregnancies 20 or more weeks:______/ Date Last Pregnancy Ended:______
Multivitamin Consumption (How often did she take a MV?)
How often the month prior to pregnancy?______/ How often during pregnancy?______
Cigarette Usage/Day / Alcohol Intake Drinks/Week
Per Day 3 months prior to Pregnancy:______
Per Day Currently:______/ Drinks/Week 3 months prior to Pregnancy:______
Drinks/Week Currently:______
Any Pregnancy History
Low Birth Weight / Premature Birth / Gestational Diabetes
Preeclampsia / Fetal or Neonatal Loss or 2 or more Spontaneous Abortions
Health Information-Post-partum
Postpartum Information
Actual Delivery Date:______/ Weight at delivery:______/ Weight Gained during Pregnancy:______
C-section Delivery / on WIC During Most Recent Pregnancy / Diabetes Mellitus
Hypertension or Pre-hypertension
Has Not Received Prenatal Care Yet / Date Prenatal Care Began:______
Requires Food Package III: Yes No / Date verified:______
Cigarette Usage/Day / Alcohol Intake Drinks/Week
Per Day Last 3 months of Pregnancy:______
Per Day Currently:______/ Drinks/Week Last 3 months of Pregnancy:______
Drinks/Week Currently:______
Most Recent Pregnancy History
Low Birth Weight / Premature Birth
Multi-fetal Gestation / Fetal or Neonatal Loss or 2 or more Spontaneous Abortions
Any History Of
Diabetes Mellitus / Gestational Diabetes / Preeclampsia
Infant(s) Born from this Pregnancy (this info needs to be gathered for each infant if multiples)
Infant Status at Birth: Live at Postpartum Visit Not Alive at Postpartum Visit Stillborn, Miscarriage, or Abortion
Neonatal Death (live 0-28 Days)
Gender: Female Male / In Foster Care? Yes No / Birth Weight: ______Birth Length: ______
Was the infant ever breastfed: Yes No Unknown
Breastfeeding Now: Yes No
If Yes, Date Breastfeeding verified:______If No, reason why stopped breastfeeding: ______
Date Breastfeeding Began: ______Date Breastfeeding Ended:______
Amount of Breastfeeding:
Fully Breastfeeding Mostly-Breastfeeding Some-Breastfeeding Non-Breastfeeding
If not Fully Breastfeeding, Date Supplemental Feeding Began:______
Date Solids were introduced:______OR Not Applicable
Height, Weight, and Blood
Measurement Date:______
Length/Height:______inches______1/8th
Weight:______lbs ______ounces / Date for Blood work: ______
Hgb:______HCT:______
Reason Blood Work not Collected (write note):
Medical Religious Other
VENA Tab/Nutrition Assessment
Results of VENA Contact:
Nutrition Education/Materials Given
NE Topics covered and Materials Given:
Referrals
Referrals Given:
Food Package:
Comments
THIS INSTITUTION IS AN EQUAL OPPORTUNITY PROVIDER.
1/19/11